Whats New in the Patient Safety World
June 2013
Anesthesia Choice for TJR in Sleep Apnea Patients
Weve done a whole
host of columns on the risks of surgery in patients with obstructive sleep
apnea (OSA), recognized or unrecognized (see the list at the end of todays
column). A couple key principles in managing such patients are to (1) use
multimodality analgesic techniques so that post-op use of opioids can be
minimized and (2) minimize the use of other drugs that might promote airway
collapse or suppress respiration. Choice of anesthesia for such patients has
always been an item for discussion but there has been no consensus and most
such discussions are based on theoretical considerations, expert opinions, and
anecdotal case reports rather than being evidence-based.
Now researchers from
The Hospital for Special Surgery have demonstrated that choice of anesthesia
does make a difference in outcomes (Memtsoudis
2013). They found that using
regional anesthesia instead of general anesthesia in patients with sleep apnea
undergoing total joint replacement decreased major complications by 17%. They analyzed
data from approximately 400 hospitals in the United States who submit data to a
large administrative database (Premier Inc) and looked at the types of
anesthesia used in over 30,000 sleep apnea patients undergoing primary hip or
knee arthroplasty. Approximately 11% of cases were performed under neuraxial,
15% under combined neuraxial and general, and 74% under general anesthesia.
Major complication rates for those 3 types of anesthesia were 16.0%, 17.2%, and
18.1%, respectively. After adjustment, the risk of major complications for
those undergoing surgery under neuraxial or combined neuraxial-general
anesthesia was 17% lower than those undergoing general anesthesia.
Though this was a
retrospective study rather than a randomized controlled trial it does provide at
least some evidence that regional anesthesia may be preferable in this patient
population, at least for major joint replacement surgery. Whether regional or
neuraxial techniques have fewer major complications in other types of surgery
in patients with OSA needs to be addressed in further studies.
Our prior columns on obstructive sleep apnea in the perioperative period:
Patient Safety Tips of the Week:
June 10, 2008 Monitoring the Postoperative COPD Patient
August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period
August 17, 2010 Preoperative Consultation Time to Change
July 13, 2010 Postoperative
Opioid-Induced Respiratory Depression
February 22, 2011 Rethinking
Alarms
November 22, 2011 Perioperative
Management of Sleep Apnea Disappointing
May 22, 2012 Update
on Preoperative Screening for Sleep Apnea
February 12, 2013 CDPH:
Lessons Learned from PCA Incident
February 19, 2013 Practical
Postoperative Pain Management
March 26, 2013 Failure
to Recognize Sleep Apnea Before Surgery
Whats New in the Patient Safety World columns:
July 2010 Obstructive Sleep Apnea in the General Inpatient Population
November 2010 More on Preoperative Screening for Obstructive Sleep Apnea
March 2012 Postoperative Complications with Obstructive Sleep Apnea
References:
Memtsoudis SG, Stundner O, Rasul R, et al. Sleep Apnea and Total Joint Arthroplasty under Various Types of Anesthesia: A Population-Based Study of Perioperative Outcomes. Regional Anesthesia & Pain Medicine.2013; POST AUTHOR CORRECTIONS, published online ahead of print 3 April 2013
doi: 10.1097/AAP.0b013e31828d0173
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